Provider Demographics
NPI:1619265709
Name:EGGEHORN, BREANNA SHANEA (BCBA)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:SHANEA
Last Name:EGGEHORN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 RANCH DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4148
Mailing Address - Country:US
Mailing Address - Phone:626-736-3434
Mailing Address - Fax:
Practice Address - Street 1:4840 RANCH DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4148
Practice Address - Country:US
Practice Address - Phone:626-736-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CO1-14-17186103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator